Every finding on record at Good Samaritan Society - Syracuse

Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain the cleanliness and condition of ventilation ceiling covers and walls in 20 ( Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509] of 54 occupied resident rooms in the facility. The facility census was 54. Findings are:Observations of the facility environment on 6/24/2026 between 8:00 AM and 11:00 AM revealed that the ventilation system in resident bathrooms in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509 had an accumulation of a fuzzy gray substance that resembled dust. The walls in resident rooms 108, 109, 113 and 402 had deep scratches and gouged areas of the drywall behind the furniture in those rooms. Observation on 06/29/2026 between 10:00 AM and 10:30 AM with the facility Maintenance Supervisor (MS) revealed that the ventilation system in resident bathrooms in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509 had an accumulation of a gray fuzzy substance that resembled dust present on the ventilation covers in those resident room bathrooms. Observation revealed that the walls in resident rooms 108, 109, 113 and 402 had deep scratches and gouged areas of the drywall behind the furniture in those rooms. Interview on 06/29/2026 at 10:33 AM Interview with the MS confirmed that the ventilation covers in resident bathrooms in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509 had an accumulation of a fuzzy gray substance that resembled dust and was unsure of when they had last been cleaned by housekeeping. The MS confirmed that the walls in resident rooms 108, 109, 113 and 402 had deep scratches and gouged areas of the drywall behind the furniture in those rooms. Record review of Maintenance Requests Sheets since 6/1/26 revealed that the scratches in the walls in rooms [ROOM NUMBER] had been identified and a maintenance request logged. The date and department signature of completion were left blank. room [ROOM NUMBER] had not been identified with wall scratches on the maintenance log. Interview on 06/29/2026 at 12:35 PM with the facility Administrator confirmed that the Maintenance Request Sheets contained requests for resident rooms 108, 113 and 402 to fix scratches in the drywall but that those had not been completed or addressed. The Administrator confirmed that the housekeeping did not have any cleaning logs or schedules. Interview on 06/30/2026 at 10:22 AM with the Housekeeping/Laundry Supervisor (HLS) confirmed that no cleaning schedules were completed for the cleaning of the resident rooms and the HLS could not identify when the ventilation covers had last been cleaned. The HLS confirmed that the ventilation covers in resident bathrooms should be cleaned at least quarterly and was unable to confirm that this was done.

Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure that ventilation systems were operational in resident bathrooms in 20 (Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509) of 54 occupied resident rooms in the facility. The facility census was 54. Findings are:Record review of a facility policy entitled HVAC systems, Resource Packet dated reviewed/revised 12/18/2025 revealed the following:Indoor Environmental Quality and Monitoring Overview:Indoor environmental quality (IEQ) is defined as the general comfort, health and well-being of residents, patients and staff members occupying our buildings related to the levels of humidity, ventilation and air circulation, volume of noise, adequacy of lighting and any other environmental conditions within the structure. Generally, people spend the majority of their time indoors. This is especially true of our residents and patients in Society locations. The quality of the indoor environment is essential to the well-being of those exposed to the environment. The ancillary services director or designee is responsible for the development and sustainability of an indoor environmental quality program that promotes the general comfort, health and well-being of our residents, patients and staff members as their work can have the greatest impact on the indoor environment by reducing or eliminating pollutants and reducing exposures. The areas that impact the comfort of building occupants include temperature (surface and air), fresh air, humidity, air movement and odors.General HVAC Maintenance: PROCEDURE4. Monitoring of HVAC systems should occur to validate that the equipment is working as designed and that the system is adequate to meet the needs of the building.Monitoring Air Exchanges and Pressures: To provide procedure for the management of indoor air quality through the monitoring of air exchanges and pressures PROCEDURE: In order to maintain proper air balancing, air exchange equipment (smoke and fire dampers, bathroom exhaust fans, filters in HVAC systems, etc.) should be inspected and maintained on a regular basis. This will help to ensure that the designed amount of air is added or taken away from a given space. Observations of the facility environment on 6/24/2026 between 8:00 AM and 11:00 AM revealed that the ventilation system in resident bathrooms in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509 did not draw a one-ply square of tissue to the surface of the ventilation covers in resident bathrooms. The fact that the tissue square was not drawn to the cover indicated that the system was non-operational at the time of the observation. Observation on 06/29/2026 between 10:00 AM and 10:30 AM with the facility Maintenance Supervisor (MS) revealed that the ventilation system in resident bathrooms in rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 115, 209, 210, 211, 213, 402 and 509 did not draw a one-ply square of tissue to the surface of the ventilation covers in resident bathrooms. The fact that the tissue square was not drawn to the cover indicated that the system was non-operational at the time of the observation. Interview on 06/29/2026 at 10:33 AM with the MS confirmed the fact that the tissue square did not draw a one-ply square of tissue to the surface of the ventilation covers in resident bathrooms. The fact that the tissue square was not drawn to the cover indicated that the system was non-operational at the time of the observation. The MS confirmed there was no documentation of when the ventilation systems had last been checked for draw and was not aware of when the system had last been operational.

Licensure Reference Number 12-006.09Based on observation, record review and interview the facility failed to develop a comprehensive care plan for a continuous positive pressure (CPAP a ventilation device that blows a gentle stream of air into the nose during sleep to keep the airway open) for 1 (Resident 43) of 16 Residents Sampled. The facility identified a census of 54.The findings are:A.Record review of a facility policy entitled 'Care Plan-R/S, LTC, Therapy & Rehab with a reviewed/revised date of 12/1/2025 revealed the following:Purpose-To develop a comprehensive care plan using an interdisciplinary team approach-To provide guidance to the interdisciplinary team in developing the initial care plan.-Comprehensive Care Pan-includes measurable objectives and timeframes to meet a residents medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment.Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of the departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders.B.Observation of Resident 43's room on 6/25/26 at 8:53 AM revealed a CPAP machine sitting on the bedside table with mask and tubing in a dated bag on the wall.Record review of Resident 43's physician admission orders dated 11/27/24 revealed an order for CPAP check settings every shift (12cm/H20) and clean machine daily.Record Review of Resident 43's Quarterly Minimum Data Set (MDS a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 6/5/26 identified the facility admitted the resident on 11/27/24 with diagnosis of hypertension, diabetes mellitus, bipolar disorder, morbid (severe) obesity due to excess calories, body mass index (BMI) 45-49.9, Adult and parkinsonism disease. Further review of the MDS identified Resident 43 had a brief interview for mental status (BIMS, a screening tool used to determine an individual's cognition in long term care and post-acute facilities) of 15 which according to the MDS manual indicated the resident was cognitively intact. Further review of the MDS revealed Resident 43 used a non-invasive mechanical ventilator while a resident.Record review of resident 43's Care Plan Report with an admission date of 11/27/2024 and a print date of 6/24/26 revealed the CPAP was not addressed on Resident 43's plan of care.In an interview with Licensed Practical Nurse-A on 6/30/26 at 8:42 AM, it was confirmed Resident 43's CPAP had not been identified on the care plan and should have been.

Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview and record review the facility staff failed to ensure hand hygiene and gloving techniques were followed during wound care for 1( Resident 34) and tube feeding for 1( Resident 17), failed to ensure wound care supplies were not contaminated for 1 (Resident 34), failed to implement interventions to prevent the spread of Covid-19 and failed to ensure the facility had a Legionella water management plan. The facility failure had the potential to effect all residents in the facility. The facility had a census of 42. Findings are: A. A record review of Resident 34's hospice wound care order dated 12/16/2024 revealed the following instructions: -Wash left heel with wound wash, dry with gauze, apply layer of Vaseline gauze to wound and cover with dry gauze dressing and secure with Medi pore tape. Hospice nurse to complete twice a week. If dressing becomes soiled or is removed, apply dry dressing and secure as needed (PRN). An observation on 01/15/2025 at 10:47 AM of wound care performed by the Clinical Care Lead (CLL) for Resident 34 revealed the following: - The CCL entered the resident room wearing a gown and face mask. They washed their hands and donned gloves. The CLL placed a pair of scissors, a pack of Kerlix (a brand of gauze bandage), a roll of tape, a foam dressing 4 x 4 (a wound care product that absorbs drainage), an open package of Vaseline gauze (a sterile non-adhesive wound dressing that's made of fine mesh gauze and white petrolatum) and a bottle of wound cleanser directly on the residents' bed. The resident raised their left leg and the CLL removed the soiled bandage from the residents' foot by cutting the kerlix with the scissors and discarded the dressing in the trash. The CCL removed their gloves and donned clean gloves. The CCL did not use hand sanitizer or wash their hands between taking gloves off and replacing them. The CLL opened the roll of kerlix and cut a portion of it off with the scissors. The scissors were placed directly on the residents' bed. The CCL soaked a piece of kerlix with wound cleaner and wiped the residents left heel wound and discarded the wet kerlix. The CCL used the scissors, which had not been cleaned, to cut a piece of Vaseline gauze. The scissors were placed directly on the bed. The Vaseline gauze was placed on the open area of the wound. The CCL opened a foam dressing package, placed the dressing over the wound and secured it in place by wrapping the remaining kerlix over it. The CCL cut a piece of tape and used it to secure the dressing in place. The CLL secured the wound care dressings in a plastic container and washed their hands, removed their gown and face mask and exited the room. An interview on 01/15/2025 at 11:05 AM with the CLL confirmed they had not washed their hands or used hand sanitizer between glove changes and they should have done so. The CLL confirmed the scissors should have been cleaned in between cutting the dirty dressing and the clean kerlix and the wound care supplies should have been placed on a barrier sheet, not directly on the residents' bed. A record review of the facility Hand Hygiene (hygiene - the practice of keeping clean to prevent disease and maintain good health) policy dated 3/29/2022 revealed the following information: -Policy All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 Moments of Hand Hygiene and 2 Zones of Hand Hygiene. 1. Entering Room. 2. Before Clean Task 3. After Bodily Fluid/Glove removal 4. Exiting Room 5. Zones: Patient zone and Health care zone. The preferred method of hand hygiene for most patient care settings is the use of waterless alcohol-based hand sanitizer. -Gloves are a protective barrier for the Health Care Worker (HCW) according to standard precautions. 1. Gloves are never to be reused or sanitized. 2. Hand hygiene should be performed after glove removal. -Procedure. HCW will use waterless alcohol-based hand sanitizer or soap and water to clean their hands: -When entering patient room. If gloves are used to perform a clean/aseptic procedure, hand hygiene must be completed before donning gloves. After removing gloves regardless of task completed. After contact with a patients' non-intact skin, wound dressings, secretions, excretions, mucous membranes, as long as hands are not soiled. B. A record review of the Infection Control Assessment and Promotion Program (ICAP) Summary of Recommendations for Covid-19 in a long-term care facility, revised on 05/11/2013 under the heading Isolation of Resident Identified to have Covid-19 (Red Zone) states that Resident door should be kept closed. On 1/13/2025 the facility provided a list of residents who were positive for Covid-19. These residents were in the following rooms.:100, 102,103, 104, 106, 107, 109, 112, 201, 205, 207, 213, 210, 301, 311, 312, 313, 316, 402. 405, 411 and 500. An observation on 1/13/2025 at 9:56 AM revealed the doors to rooms 201, 205, 207, 213, and 312 were open. An observation on 1/14/25 at 7:50 AM revealed the doors to rooms 312, 402, 210, 205, and 109 were open. An observation on 1/15/2024 at 9:15 AM revealed the doors to rooms 112, 109, 106, 102, 201, 207, 210, 213, and 500 were open. An interview on 1/15/2025 at 9:15 AM with the Clinical Care Lead (CCL) confirmed having the doors open in a Covid-19 positive room was an infection control breach. The CCL confirmed the Airborne Precautions from the Centers for Disease Control and Prevention (CDC) sign on each door stated the doors were to be kept closed at all times. The CCL confirmed the facility is following the Infection Control Assessment and Promotion Program (ICAP) Summary of Recommendations for Covid-19 in a long-term care facility, revised 5/11/23. The CCL confirmed the ICAP summary stated the Resident door should be kept closed. C. An interview on 1/16/2024 at 9:40 AM with the Maintenance Director (MD) confirmed the facility uses The Equipment Lifecycle System (TELS system - a system which helps with life safety, asset management, maintenance and repairs and is used to track and document repairs and maintenance in a facility). The MD was unable to produce a text and flow diagram (a visual representation of a process or workflow where each step is described with text and connected by arrows to show the sequence of actions) to show the areas where Legionella and other waterborne pathogens could grow and spread in the facility's water system. An interview on 01/16/2024 at 9:45 AM with the Facility Administrator confirmed they did not know if there was a Legionella Water Management program team and did not know if there was a water flow diagram for the facility. An interview on 1/16/2024 at 10:12 AM with the facility Maintenance Director confirmed there was not a water management program team in the facility, The facility did not have a water system flow diagram and there were no confirmatory procedures to show that the program is being followed as written and to validate that the program is effective. The MD confirmed the facility did not have the measures required by the facility policy to prevent the growth of Legionella. A record review of the Company's Plumbing Systems, Resource packet Policy, containing the Legionnaires disease and water management program Policy revised on 1/17/2024 revealed the following information: -Policy -All Good Samaritan Society rehab/skilled locations will identify a water management team at their location that will annually and with any major maintenance and water service change, identify where Legionella could grow. This team will determine the water management program for the location. Revisions will be made as needed to the water management plan. Documentation of control measures will occur in the Society's approved environmental services management software system. -Water Management Program The written program should include at least the following: Program team including names, titles, contact information and roles on the team. At a minimum the team should include: Someone who understands accreditation standards and licensing requirements, Someone with expertise in infection prevention, A clinician with expertise in infectious diseases and Risk and Quality management staff. Describe your building water system using a flow diagram; this should be a simple diagram that is easily understood by all team members. Identify areas where Legionella could grow and spread: Using the water system flow diagram, identify where potentially hazardous conditions could occur in your building water system, -Apply control measures: Control measures and limits should be established for each control point. Include confirmatory procedures to show that the program is being followed as written and to validate that the program is effective. 17285 D. Record review of Resident 17's Quarterly MDS (Minimum Data Set - a comprehensive standardized assessment of resident's functional capabilities and health needs) dated 11/8/24 revealed an admitted [DATE] and diagnoses that included Malignant Neoplasm of Oropharynx; Dysphagia (difficulty swallowing); and Gastrostomy Status (presence of a feeding tube in the stomach for nutrition and hydration support). The MDS identified BIMS (Brief Interview for Mental Status, aids in detecting cognitive impairment) score of 14 which indicated the resident was cognitively intact. The MDS identified Resident 17 did not eat due to a medical condition and had a feeding tube while a resident with 51% or more calories by feeding tube and 501 cc or more for fluids. Record review of Resident 17's Physician Orders revealed the following orders: - 12/01/2023 NPO (nothing by mouth) diet, - 11/08/2024 Nutren 2.0 Oral Liquid (Nutritional Supplements) Give 250 ml via G-Tube three times a day with minimum of 100 ml water before and after each feeding - By Gravity. Observation on 01/15/25 at 08:20 AM revealed Resident 17 was in isolation due to use of the feeding tube. A sign on the door indicated that personal protective equipment, including gowns, gloves, N-95 mask, and eye protection were required during cares. Observation on 01/15/25 at 08:20 AM revealed LPN (Licensed Practical Nurse) C knocked on the door, entered the room in goggles, an N 95 Mask, a gown and gloves. LPN C explained the procedure to Resident 17, cleaned the bedside table with a disinfectant cloth and placed a tissue barrier. With the same gloves and no hand hygiene performed, LPN C reached into the pocket of their uniform pants, retrieved a set of keys, unlocked the supply cabinet and replaced the keys into the same pocket. With the same gloves in place and no hand hygiene performed, LPN C placed 3 cups on the barrier and retrieved a bottle of tube feeding from a box on the floor. LPN C shook the tube feeding well, opened and poured the contents of the bottle into a cup. LPN C retrieved an open bottle of distilled water from the floor and poured 240 cc into one of the cups. LPN C proceeded to check placement and administer tube feeding with water flushes as ordered. During the administration LPN C did not change gloves or perform hand hygiene. LPN C disconnected the syringe and capped the gastrostomy tube. With the same gloves in place and no hand hygiene performed, LPN C adjusted the 4x4 gauze dressing at the gastrostomy site, then adjusted Resident 17's clothing. With the same gloves in use and no hand hygiene, LPN C rinsed out the syringe and placed it back into the cabinet where clean supplies were stored. Interview on 01/15/25 at 8:35 AM with LPN C confirmed that the facility always keeps tube feeding supplies on the floor and that soiled gloves should have been removed and hygiene performed after the keys were touched. LPN C confirmed that the keys would have been considered soiled because they were in a pocket. Interview on 01/15/25 at 02:04 PM with Clinical Care Lead Coordinator (CCLC) confirmed that tube feeding supplies and water should not be stored on the floor and that hand hygiene and a glove change should have been performed after the keys were touched. The CCLC confirmed that the keys would be considered soiled as they were in a pocket.

Licensure Reference Number NAC 175 12-006.04(F)(i)5 Based on record review and interview the facility staff failed to notify the physician and responsible party regarding missed/unavailable doses of medication for 1 (Resident 18) of 8 resident's reviewed. The facility staff identified a census of 42. Findings are: Record review of Resident 18's Face Sheet dated 01/15/2025 revealed Resident 18 was admitted to the facility on [DATE]. Record review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 11/04/2024 revealed the facility staff assessed the resident's use of anticonvulsant medication. This MDS also assessed Resident's mental status and documented severe impairment. Record review of Resident 18's Medication Administration Record (MAR, a record of how the Resident's medications are administered) for Phenytoin (an anticonvulsant medication) Oral Suspension 125 MG/ML (Milligram/Milliliter), give 8 ML by mouth two times a day revealed 19 missed doses total for November and December 2024. The missed doses for November 2024 revealed the medication was unavailable for a total of 16 doses, and December 2024 revealed 3 doses were unavailable. 1/15/24 @ 1:15 PM Interview with Clinical Care Leader (CCL, A nurse that supervises the day-to-day cares in the facility) confirmed that the staff had not alerted the pharmacy that the medication was unavailable. The CCL revealed the staff had not notified the physician or POA of the missed doses of Phenytoin. Record review of the facility policy dated 12/23/2024 revealed the facility must immediately inform the resident, consult, the resident's physician and notify, consistent with his or her authority, the resident representative.

Licensure Reference Number 175 NAC 12-006.09D Based on observation, record review and interview; the facility failed to ensure the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) was coded to reflect the resident used a wander guard system (a medical alert device used to send an alert to staff or sound an alarm to prevent elopement for wandering residents)for 1 (Resident 6) of 11 residents that utilized a wander guard system. The facility census was 42. Findings are: Observation on 01/16/25 at 8:34 AM revealed Resident 6 seated in a recliner in their room. Resident 6 had a wander guard system bracelet present on the right wrist. Interview on 01/15/25 at 3:18 PM with the facility Social Worker confirmed that the wander guard was placed on Resident 6 on 12/19/24. The Social Worker further confirmed that Resident 6 was at risk for elopement. Record review of Resident 6's CCP (Comprehensive Care Plan, a individualized plan of care which identifies care needs for the resident) dated revised 12/19/24 revealed that Resident 6 had the potential for elopement related to exit-seeking due to Dementia. Interventions included: Wander guard used to alert staff to resident near exits. This was initiated on 12/19/2024. Record review of Resident 6's annual MDS annual 12/26/24, with a review period between 12/20/24 and 12/26/24, revealed an admitted [DATE] and diagnoses that included Unspecified Dementia, Depression and Generalized anxiety Disorder. Resident 6's MDS identified a BIMS (Brief Interview for Mental Status, aides in detecting cognitive impairment) score of 05 which indicated severely impaired cognitive ability, wandering occurred 1-3 days during the assessment review dates, no impairment with range of motion, walker and wheelchair use, independent while in a manual wheelchair with wheeling 50 feet - 150 feet, and no wander guard used. Interview on 01/16/25 at 9:40 AM with the MDS Coordinator confirmed the information in the CCP and that a wander guard was placed on Resident 6 on 12/19/24. The MDS Coordinator confirmed that there was an error in the MDS and that the wander guard system was not coded correctly in Section P0200 E of the MDS to identify the use of a wander guard system for Resident 6. Record review of facility Order Listing Report dated 1/16/25 revealed a total of 11 residents with orders for a wander guard system.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review; the facility failed to re-evaluate elopement risk and monitor the functioning of the wander guard system (a medical alert device used to send an alert to staff or sound an alarm to prevent elopement for wandering residents) for 1 (Resident 6) of 11 residents that utilized a wander guard system. The facility census was 42. Findings are: Record review of a facility policy entitled Elopement- Rehab/Skilled & Adult Day Services, dated 8/16/24 revealed the following: - During the stay: 1. Residents will be assessed and monitored in the following ways: a. The Elopement Risk UDA (assessment) will be completed for all residents with the quarterly, annual and significant change MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) assessments. The Elopement Risk UDA can also be triggered PRN (as needed) when elopement risk is identified (i.e. change in resident's medical condition and/or cognitive status, resident who is exhibiting a new mood or behavior or a new attempt to elope). Record review of Resident 6's annual MDS dated [DATE], with a review period between 12/20/24 and 12/26/24, revealed an admitted [DATE] and diagnoses that included Unspecified Dementia, Depression and Generalized anxiety Disorder. Resident 6's MDS identified a BIMS (Brief Interview for Mental Status, aides in detecting cognitive impairment) score of 05 which indicated severely impaired cognitive ability, wandering occurred 1-3 days during the assessment review dates, no impairment with range of motion, walker and wheelchair use, independent while in a manual wheelchair with wheeling 50 feet - 150 feet, and no wander guard used. Record review of Resident 6's CCP (Comprehensive Care Plan, an individualized plan of care which identifies care needs for the resident) dated revised 12/19/24 revealed that Resident 6 had the potential for elopement related to exit-seeking due to Dementia. Interventions included: Wander guard used to alert staff to resident near exits. This was initiated on 12/19/2024. Record review of an Elopement Risk Assessment for Resident 6, completed on 6/14/24, revealed that Resident 6 was identified not at risk for elopement. Record review of Resident 6's Electronic Medical Record, including elopement assessments, revealed that no elopement assessments had been completed after 6/14/24 for Resident 6. Record review of Physician Orders revealed the following orders for Resident 6: - 12/16/2024: Wander guard for increase confusion and exit seeking. - 12/19/24: Check function of wander guard bracelet Q (every) shift two times a day for wander guard integrity. Record review of Resident 6's Progress Notes revealed the following: - 12/13/2024: Resident presenting with higher confusion and asking when [gender] can leave. Resident restless but was able to be redirected. Wander guard was placed for safety. Family notified, fax sent to MD (Medical Doctor). - 12/16/24 14:31: Dr. noted fax regarding wander guard bracelet. - 12/16/24 15:00: Dr. ok to wander guard. Placed in oreders [sp]. - 12/27/24 12:38: Resident wondered the facility lost several times. This MSW [master Social Work] observed and redirected resident several times. Resident requires redirection, cues, and reminders. Memory loss and low recollection on what is said. Observation on 01/16/25 at 8:34 AM revealed Resident 6 seated in a recliner in their room. Resident 6 had a wander guard system bracelet present on the right wrist. Interview on 01/16/25 at 8:40 AM with LPN (Licensed Practical Nurse) A revealed the wander guards are checked by the medication aides and documented on the Electronic MAR / TAR (Medication Administration Record / Treatment Administration Record) in the resident's record. Observation on 01/16/25 at 8:41 AM with MA (Medication Aide) B revealed that MA B entered Resident 6's room and checked the wander guard system with the testing device. The light on the wander guard bracelet, on Resident 6's right arm, turned green which indicated that it functioned properly. Interview on 01/16/25 at 8:43 AM with MA B revealed the order for the wander guard had not populated onto Resident 6's Electronic MAR /TAR and was not available to be documented as completed and checked. Interview on 01/16/25 at 8:45 AM LPN A confirmed the wander guard checks had not populated onto the Electronic MAR/TAR dated December 2024 and January 2025 so those checks could not be documented as completed. LPN A confirmed that wander guard system checks were to be done BID (twice a day) and should have started on 12/19/24. LPN A reviewed Resident 6's Electronic MAR / TAR dated December 2024 and January 2025 and confirmed those checks were not completed or documented. Interview on 01/16/25 at 01:26 PM with CCLC (Clinical Care Lead Coordinator) confirmed that an elopement assessment for Resident 6 had not been completed when the wander guard was initiated on 12/19/24 and should have been. The CCLC confirmed that the monitoring of the function of the wander guard for Resident 6 had not been completed or documented and should have been. Record review of facility Order Listing Report dated 1/16/25 revealed a total of 11 residents with orders for a wander guard system.

Licensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview; the facility failed to ensure 1 Resident (#18) of 9 Resident's reviewed were free from significant medication errors. The facility staff identified a census of 42. Findings are: Record review of Resident 18's Face Sheet dated 01/15/2025 revealed a diagnosis of Epilepsy and an admitted [DATE]. Record review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 11/04/2024 revealed the facility staff assessed the resident's use of anticonvulsant medication, used to treat Epilepsy. This MDS also assessed Resident's mental status and documented severe impairment. Record review of Resident 18's MAR (Medication Administration Record) revealed Phenytoin Oral Suspension 125 MG/ML (Milligram/Milliliter), give 8 ML by mouth two times a day, related to Epilepsy. Record review of the MAR revealed in November 2024, the medication was unavailable for a total of 16 doses. Further review revealed 3 doses were unavailable in December 2024 for a total of 19 unavailable doses. Record review of Resident 18's (CCP) Comprehensive Care Plan, a written plan to meet the needs of the resident, dated 08/22/2024 revealed the following, -Focus: Resident 18 has a seizure disorder. -Goal: Resident 18 will remain free from injury related to seizure activity through review date. -Interventions: Seizure Precautions: Do not leave resident alone during a seizure; protect from injury; if resident is out of bed, help to the floor to prevent injury; remove or loosen tight clothing don't attempt to restrain resident during a seizure as this could make the convulsions more severe; protect from onlookers, draw curtain etc. -Post seizure treatment: Turn on side with head back, hyper-extended to prevent aspiration; keep airway open; after seizure take vital signs and neuro check; monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. -Notify nurse ASAP if seizure activity occurs. An interview on 1/13/2025 at 7:38 AM with Resident 18's POA (Power of Attorney-An appointed individual to make decisions for the Resident, when the Resident cannot make decisions for themselves) revealed a significant medication was unavailable for Resident 18 several times in October and November. The POA was unable to give a date that they received this information. An interview on 01/15/2025 at 1:15 PM with the CCL (Clinical Care Leader) revealed the staff had not notified the pharmacy that Resident 18 was out of Phenytoin Oral Suspension, and this was a significant medication error . Record review of the facility policy titled Medication; Acquisition receiving dispensing and storage dated 3/29/24. The Policy/Procedure revealed the licensed nursing employees are responsible for ordering from the pharmacy and checking all new orders of medications. Discrepancies and omissions are to be reported promptly to the issuing pharmacy and the charge nurse. Record review of the Facility policy titled Local pharmacy medications ordering dated 9/03/24 revealed, If the medication has been reordered and not received on the next delivery, the staff are to call the pharmacy are determine why the medication was not delivered.

Licensure Reference Number 175 NAC 12.006.04C3a(6) Based on record review and interview, the facility failed to notify the practitioner of a change in condition for 1 (Resident 48) of 3 sampled residents. The facility census was 45. Findings are: Record Review of Resident 48's Electronic Health Record (EHR) revealed a progress note dated 11-11-2023 at 2:17 PM revealing Resident 48 did not go to lunch, was sleepy and Resident 48's skin was pale and cool to the touch. Record Review of Resident 48's EHR revealed a progress note dated 11-11-2023 at 2:34 PM revealing Resident 48's family representative was notified that there had been a change in Resident 48's condition and options were discussed about going to the emergency room or staying at the facility. Record Review of Resident 48's EHR revealed the absence of physician notification of a change in condition on 11-11-2023. Interview with the Director of Nursing (DON) on 01-10-2024 at 12:22 PM confirmed that there was no additional documents in Resident 48's EHR that the physician was notified of a change of condition.

Licensure reference: 175 NAC 12-006.09 Based on record review and interview, the facility failed to ensure neurological assessments were accurate and complete after a fall in accordance with facility policy for 3 [Residents 1, 2, and 3] of 3 sampled residents. The facility had a total census of 41 residents. Findings are: A. A review of facility policy titled Neurological Evaluation-Rehab/Skilled dated 2/10/23 revealed the use and procedure: Use: -Following a witnessed fall when a resident has hit his/her head -Following an unwitnessed fall -Following a resident event that results in a known or suspected head injury (e.g., hemorrhagic stroke) Policy/Procedure: -After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 minutes x 4, then every eight hours x 3 days or as directed by the provider. -Subsequent neurological evaluations should be compared to baseline and previous neurological evaluations. All items on the Neuro Check UDA should be completed with each evaluation. -Notify physician of any neurological evaluation findings which are a change from the baseline or previous evaluations. Document all physician notifications on PN-Communication/visit with Physician. B. A review on Incident Report dated 4/23/23 at 9 AM revealed Resident 1 was found sitting on the bathroom floor and holding (gender) head. Resident 1 was noted to have red [NAME] on the forehead but no swelling. Resident 1 was noted as having tremor or jerking like movements. Record review of Neuro Check forms documented in the electronic medical record completed on Resident 1 after a fall on 4/23/23 at 9 AM revealed neurological assessments were completed on the following dates and times: -4/23/23 at 9:00 AM. -4/23/23 at 9:27 AM. -4/23/23 at 11:00 AM. -4/23/23 at 2:00 PM. -4/23/23 at 8:00 PM. -4/24/23 at 8:00 PM. -4/25/23 at 1:08 PM. In an interview on 5/8/23 at 4:52 PM, the Director of Nursing (DON) confirmed no additional neurological checks could be located and that policy regarding neurological checks should be followed. The Director of Nursing (DON) confirmed that Resident 1 was receiving Xarelto. C. A review of Incident Report dated 5/2/23 at 3:40 AM revealed Resident 2 was found on the floor lying on left side. Record review of Neuro Check forms documented in the electronic medical record completed on Resident 2 after a fall on 5/3/23 at 3:40 AM revealed neurological assessments were completed on the following dates and times: -5/3/23 at 3:40 AM. -5/3/23 at 4:10 AM. -5/3/23 at 5:10 AM. -5/3/23 at 5:40 AM. -5/5/23 at 1:25 PM. -5/5/23 at 9:40 PM. -5/6/23 at 5:40 AM. In an interview on 5/8/23 at 4:55 PM, the DON confirmed no neurological checks could be located for 5/4/23. D. A review of Incident Report dated 4/16/23 at 10:15 PM revealed Resident 3 was found on fall [NAME] on Resident 3's knees. Record review of Neuro Check forms documented in the electronic medical record completed on Resident 3 after a fall on 4/16/23 at 10:15 PM revealed a neurological check was completed on 4/16/23 at 10:15 PM. The vitals signs [temperature, pulse, respiration, blood pressure and oxygen saturation] documented on the Neuro Check form were taken at 9:54 AM on 4/16/23 not at the time of the of the fall at 10:15 PM. Record review of electronic medical record did not reveal any additional neurological checks completed on 4/16/23. A review of Incident Report dated 4/17/23 at 4:30 AM revealed Resident 3 was found on floor on [NAME] next to Resident 3's bed. Record review of Neuro Check forms documented in the electronic medical record revealed the a neurological assessment was completed on 4/17/23 at 2:53 AM. The pulse on the 4/17/23 at 2:53 AM Neuro Check Form was documented from 4/16/23 at 9:54 AM and temperature, respiration, blood pressure, and oxygen saturations were from 4/17/23 at 1:30 AM. A review of Incident Report dated 4/18/23 at 2:15 PM revealed Resident 3 was found on mat beside bed. Record review of Neuro Check forms documented in the electronic medical record revealed no Neuro Checks had been completed on 4/18/23. In an interview on 5/8/23 at 4:59 PM with the DON revealed that neurological assessments were not completed on Resident 3 in accordance with the facility policy for an unwitnessed fall.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview, the facility staff failed to wear and clean Personal Protective Equipment [PPE, protective clothing designed to protect the wearer from infection, including gowns, gloves, face masks and eye protection] in a manner to prevent the potential spread of COVID 19. This had the potential to affect all the residents that resided in the facility. The facility census was 46. Findings are: A. Interview on 01/03/23 at 8:30 AM, upon entrance to the facility, with the facility Administrator revealed that staff were expected to wear an N95 mask [a particulate filtering face mask] and eye protection [goggles or face shield] to cover the eyes in the facility because there were residents that were positive for COVID 19 that resided in the facility. Observation on 01/04/23 at 2:30 PM revealed a sign posted on the door between the COVID 19 positive unit and the other areas of the nursing home that read: You are exiting a Yellow Zone [an isolation zone requiring an N95 mask and eye protection to be worn while in the zone]: Please stop in the chapel and disinfect your eyewear (goggles / glasses / face shield) and change your N95 mask every time you exit the yellow zone. Observation on 01/05/23 between 08:10 AM and 8:20 AM revealed Food Service Assistant [FSA] A exited the COVID 19 positive area of the facility. FSA A had on a surgical mask and goggles that were positioned on top of a hat on FSA A's head and were not positioned over the eyes. FSA A did not clean the goggles upon exit from the unit and did not change masks. Several residents were present in the lobby area of the facility and FSA A passed within 6 feet of these residents. FSA A proceeded to go to the kitchen with the same surgical ask and with the goggles on top of the head and not over the eyes. Interview on 01/05/23 at 08:20 AM with the Clinical Learning Development Specialist [CLDS] Registered Nurse [RN] confirmed the expectation that N95 masks and eye protection should be worn in the COVID 19 unit and in the facility. The CLDS confirmed that FSA A did not have on a N95 mask and the goggles did not cover the eyes when FSA A exited the COVID positive area. Observation on 01/05/23 at 11:42 AM revealed FSA A in the dining area setting up room trays for delivery to the units. There were 2 residents in the dining area at that time. FSA A wore a surgical mask and wore goggles positioned on top of [Gender] hat head and the goggles did not cover the eyes. Observation on 01/05/23 between 11:55 AM -12:10 PM revealed FSA A took room trays from the kitchen, thru the facility, past several residents in the lobby area, to the COVID positive hall with a surgical mask in place and goggles placed up on top of the hat on [gender] head. FSA A opened the door to the COVID 19 hall, placed the cart of room trays into the hall , announced to staff that room trays were there and closed the door to the COVID 19 unit. FSA A returned to the kitchen, got another tray of meals ,passed by several residents then took the trays to the COVID 19 positive hallway, opened the door to the COVID 19 hallway, placed the cart into the hall and closed the door. Still wearing a surgical mask and goggles on the hat, FSA A returned to the kitchen, got another tray of meals, took them through the facility and passed 4 residents in close proximity in the hallway to the dining area and proceeded to chapel outside of the COVID 19 positive hall. FSA A stopped, took off the surgical mask and put on an N95 and put his goggles down to cover [gender] eyes. FSA A took the tray of meals through the COVID 19 hall down to the 500 hall. FSA A returned through the COVID 19 unit, stopped and took off the N95 mask and threw it away, took a surgical mask from [gender] pants pocket and placed it on [gender] face. FSA A did not put on an N95 masks or clean the goggles after leaving the COVID unit. FSA A went back to the dining area and continued to serve meals to several residents. Interview on 01/05/23 at 12:15 PM with FSA A confirmed that [gender] wore a surgical mask and goggles on [gender] hat while passing trays to the COVID 19 positive hall and had passed several residents in the hall. FSA A confirmed that [gender] did not clean his goggles after coming off the COVID 19 hall or put on an N95 mask. Interview on 01/05/23 at 12:17 PM with the CLDS RN confirmed the expectation that N95 masks should be worn when in the facility due to residents positive with COVID 19 in the facility. The CLDS RN confirmed that goggles should be worn in a position to cover the eyes for protection. B. Observation on 01/09/23 at 08:37 AM revealed Nursing Assistant [NA] B entered room [ROOM NUMBER] with a resident. NA B had goggles sitting on top of [gender] head and they did not cover the eyes. Interview on 01/09/23 at 08:40 AM with NA B confirmed that the goggles were on top of [gender] head and not over the eyes. Interview on 1/9/23 at 8:47 AM with the facility Administrator confirmed that goggles should be worn to cover the eyes to provide protection. 40338 On 01/04/22 at 08:10 AM an observation of FSA-A on the yellow zone (isolation precautions requiring an N95 mask and eye protection) with two dietary carts. FSA-A's eye protection was placed on (gender)baseball cap and was not covering eyes.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(3) Based on record review and interview; the facility staff failed to give a choice for COVID-19 treatment upon a positive COVID-19 diagnosis for 3 (Resident 3, 27 and 37) of 3 sampled residents. The facility staff identified a census of 46. The findings are: A. Record review of an email dated 12/31/22 from ICAP (Infection Control Assessment Promotion Program) to the Administrator regarding recommendations for the COVID-19 outbreak with residents that occurred on 12/31/22 revealed a recommendation for COVID-19 therapeutic treatment for as many residents as eligible. B. Record review of Resident 3's progress note dated 12/31/22 revealed Resident 3 had a positive COVID-19 test. Review of Resident 3's MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 12/5/22 revealed a BIMS (Brief Interview for Mental Status) score of 14. According to the MDS Manuel a score of 13-15 indicates a resident is cognitively intact. On 01/05/23 at 09:30 AM an interview was conducted with Resident 3 which revealed that (gender) tested positive for COVID-19 on 12/31/22 at the emergency room and had a temp of 102 degrees Fahrenheit and a bad cold. Resident 3 stated that (gender) did not get offered COVID-19 treatment from the facility and no one from the facility spoke to (gender) about the possibility of getting COVID-19 treatment. C. Record review of Resident 27's progress notes dated 12/31/22 revealed Resident 27 had a positive COVID-19 test. Record review of Resident 27's MDS dated [DATE] revealed a BIMS of 15. On 01/05/23 at 09:40 AM an interview was conducted with Resident 27 which revealed (gender) was told (gender) had a positive COVID-19 test on 12/31/22. Resident 27 stated (gender) does have a cold with coughing. Resident 27 stated (gender) didn't get offered any COVID-19 treatments and would have considered them if (gender) had been offered. D. Record review of Resident 37's progress note dated 12/31/22 revealed Resident 37 had a positive COVID-19 test. Record review of Resident 37's MDS dated revealed a BIMS of 12. On 01/05/23 at 09:20 AM an interview was conducted with Resident 37 which revealed (gender) was told (gender) had a positive COVID-19 test on 12/31/22 and reported symptoms of coughing and being tired. Resident 37 stated (gender) no one told (gender) about COVID-19 treatments or offered COVID-19 treatments. On 01/05/22 at 07:15 AM an interview was conducted with the DON (Director of Nursing) which confirmed the recommendations from ICAP were not followed regarding COVID-19 treatments for eligible COVID-19 positive residents. The DON further confirmed there is no documentation of an evaluation or assessment of COVID-19 positive residents eligibility to receive COVID-19 treatment.

Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure a working ventilation system in 9 resident bathrooms (rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301) of 44 occupied resident rooms. The facility census was 46 at the time of survey. Findings are: In an interview on 1/9/23 at 07:19 AM with the Manager of Ancillary Services (MAS) confirmed the facility was unable to find ventilation check log books. During observations of the facility environment on 1/9/23 beginning at 08:20 AM with the MAS revealed observations that the ventilation system in the resident bathrooms of rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301 did not draw a 1 ply square of tissue to the surface of the ventilation covers in the resident bathrooms. In an interview on 1/9/23 at 08:40 AM with the MAS confirmed the ventilation check logs did not exist and that the ventilation in rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301 were not functioning. It was also confirmed by the MAS that MAS had not been doing any bathroom ventilation system checks.

Licensure Reference: 175 NAC 12-006.02(8). Based on record review and interview, the facility failed to investigate potential inappropriate touch involving 2 [Residents 2 and 3] of 3 sampled residents and failed to implement interventions of increased monitoring for 1 [Resident 2] of 3 sampled residents following facility investigation of sexual behaviors. The facility had a total census of 43 residents. Findings are: A. A review of Resident 3's Progress Notes revealed a Progress Note dated 5/29/22 that stated a male resident had hand over Resident 3's crotch area over Resident 3's clothes and was feeling Resident 3. Male resident was asked to remove hands from Resident 3's crotch. A review of Resident 2's Progress Notes revealed a Progress Note dated 5/29/22 that stated Resident 2 had hand in female resident's crotch area over female clothes and was feeling female resident. Resident 2 was asked to remove hands from female resident's crotch. In an interview on 9/13/22 at 12:34 PM, Registered Nurse A reported information regarding incident was emailed to administrative staff. In an interview on 9/13/22 at 11:41 AM, the Administrator reported being aware of hand holding only between the two residents. The Administrator stated that incident would have been reported and an investigation completed if the Administrator had been aware of the inappropriate touch. A review of facility policy titled Abuse and neglect dated 3/31/22 revealed the following: -Alleged or suspected violations involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. B. A review of facility investigation dated 8/22/22 revealed Resident 2 was observed performing oral sexual act on Resident 1. Residents 1 and 2 were immediately separated. The facility investigation identified the following measure were to be put in place to prevent a reoccurrence: Resident 1 was relocated within the building to a room that supports a higher level of monitoring of Resident 1. A review of Resident 2's care plan did not reveal any interventions related to Resident 2's sexual behaviors. In an interview on 9/13/22 at 12:59 PM, Nurse Aide B reported being unaware of any additional monitoring requirements for Resident 2. Nurse Aide B reported doing regular monitoring on Resident 2 which was every 2-3 hours. In an interview on 9/13/22 at 2:03 PM, Nurse Aide C reported checking on Resident 2 every 15-30 minutes. In an interview on 9/13/22 at 2:12 PM, Nurse Aide E reported not being aware of any specific timeframes for checking on Resident 2. In an interview on 9/13/22 at 2:24 PM, the Director of Nursing reported staff have been keeping an eye on him. The Director of Nursing confirmed no specific time frames for checking on Resident 2 had been established. In an interview on 9/13/22 at 11:41 AM and 12:11 PM, the Administrator reported an expectation that Resident 2 be checked on every hour and that office staff are to keep an eye on Resident 2. The Administrator confirmed that Resident 2's care plan had not been updated to include interventions related to sexual behaviors.

Based on record review and interview, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice [SNFABN] to inform the resident or responsible party of the potential liability for payment and the right to request a standard claim appeal be sent to the fiscal intermediary for a payment decision for 2 (Residents 28 and 34) of 3 resident beneficiary notices reviewed. The facility census was 44. Findings are: A. Record review of a Centers for Medicare and Medicaid Services and Certification letter dated 09/20 revealed that the Skilled Nursing Facility must inform the beneficiary of potential liability for payment for non-covered services upon completion of Medicare part A services. The SNF's responsibility to provide notice can be fulfilled by use of the SNFABN. The SNFABN informs the beneficiary of the right to have a claim submitted to the fiscal intermediary for a decision by Medicare. Issuing the Notice of Medicare Non Coverage [NOMNC] to a beneficiary only conveys notice of the right to an expedited review of a service termination and does not fulfill the providers obligation to advise the beneficiary of potential liability of payment. The provider must still issue the SNFABN to address liability. B. Record review of a facility Policy and Procedure Advanced Beneficiary Notice of Non coverage (ABN) dated revised 8/2020 revealed that the notice was required to inform the beneficiary and or responsible party that Medicare was not likely to provide coverage in a specific case. The notice must be delivered far enough in advance that the beneficiary or responsible party has time to consider the options and make an informed choice. C. Record review of Resident 28's Notice of Medicare Non Coverage [a request for an expedited appeal] revealed that Medicare services ended on 12/20/21. Resident 28 was not issued a SNFABN liability notice. D. Record review of Resident 34's Notice of Medicare Non-Coverage revealed that Medicare services ended on 12/29/21. Resident 34 was not issued a SNFABN liability notice E. Interview with Registered Nurse [RN] Case Manager A on 01/04/22 at 12:27 PM confirmed that an SNFABN had not been issued to Residents 28 and 34 and confirmed that the Notice of Medicare Non Coverage was the only notice provided to those residents. RN Case Manager A was not aware of the requirement to issue an SNFABN upon discharge from Medicare part A services. F. Interview with the facility Social Services Director confirmed that Residents 28 and 34 had not received a SNFABN notice of potential liability as required.

Licensure Reference Number 175 NAC 12-006.02(8) Based on interview and record review, the facility failed to report a fall with major injury to the required state agencies for 1 (Resident 5) of 12 sampled residents. The facility had a total census of 44 residents. The findings are: A review of Resident 5's Admission Record revealed Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an incident report dated 10/20/21 at 6:30 PM revealed Resident 5 was found on the floor in the activity room. Factors that contributed to the fall were listed as, reaching to pick up a card on the floor and poor safety awareness. Actions to prevent reoccurrence listed were resident education/training, monitoring resident, reminders to resident to call for help to pick objects off the floor, and resident not to be in activity room unsupervised. A review of an update dated sent to Resident 5's physician revealed Resident 5 was found sitting on the floor with their legs outstretched and was bleeding from a laceration on the nail bed of Resident 5's right big toe. Resident 5 reported pain to the right big toe, but was able to stand and walk. A review of a radiology report dated 10/21/21 for Resident 5 revealed Resident 5 had an acute right first toe fracture. An interview was conducted with the Facility Administrator (FA) on 1/5/22 at 12:36 PM. During the interview the FA confirmed Resident 5's toe fracture would be considered a significant injury. The FA also confirmed Resident 5's fall with significant injury on 10/20/21 was not reported to the required State Agencies.

Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure insulin was administered in accordance with manufacturer's directions and professional standards of practice for 1 (Resident 22) of 1 resident reviewed for insulin administration. The facility had a total census of 44 residents. The findings are: A review of Resident 22's Admission Record revealed Resident 22 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 1/6/22 at 11:10 AM, RN - I reported the facility served lunch at noon. An observation on 1/6/22 at 11:15 AM revealed Registered Nurse (RN) - I checked Resident 22's blood glucose, with a result of 184. At 11:24 AM, RN - I administered 2 units of [MEDICATION(S)] Insulin (a short-acting insulin used to treat diabetes) to Resident 22. An observation on 1/6/22 at 11:52 AM revealed Resident 22 was sitting in Resident 22's room. Resident 22 stated they would go down to the dining room for lunch at noon. An observation on 1/6/22 at 12:11 PM revealed Resident 22 was sitting in Resident 22's room. A staff member was exiting Resident 22's room. Resident 22 stated Resident 22 had fallen asleep and had not eaten yet. Resident 22 got in their wheelchair and propelled down to the dining room. An observation on 1/6/22 at 12:15 PM revealed Resident 22 received lunch and began eating. A review of Resident 22's January 2022 MAR (Medication Administration Record) revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Solution - Inject as per sliding scale (a scale used to determine the amount of insulin used based on pre-determined blood glucose levels) subcutaneously (into the fatty layer under the skin) before meals. A review of the [MEDICATION(S)] Insulin Manufacturer's Instructions for Use package insert, last revised November 2019 revealed the following: -[MEDICATION(S)] starts acting fast, so give your injection within 15 minutes before or right after you eat a meal. In an interview on 1/6/22 at 1:49 PM, the Director of Nursing (DON) confirmed Resident 22 should have eaten within 15 minutes after receiving a dose of [MEDICATION(S)] Insulin. The DON also confirmed insulin errors can be significant.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed during medication administration for 2 (Residents 15 and 16) of 3 residents observed for medication administration. The facility had a total census of 44 residents. The findings are: Observations on 1/6/22 from 8:00 AM - 8:15 AM revealed Medication Aide (MA) - G administering medications. MA - G prepared and administered medications for Resident 16. MA - G did not perform hand hygiene prior to or after administering Resident 16's medications. MA - G then prepared and administered medications for Resident 15. MA - G did not perform hand hygiene prior to or after administering Resident 15's medications. A review of the facility's Medication Administration Policy last revised 4/6/21 revealed the following information: -Procedure: -1. Wash your hands prior to beginning med pass and following the administration of medication for each resident. If hands are visibly soiled wash hands with soap and water, if hands are not visibly soiled or contaminated with body fluids use of an alcohol-based hand rub is acceptable. In an interview on 1/06/22 at 1:49 PM, the Director of nursing (DON) confirmed the expectation was that hand hygiene was performed at the start of medication administration and in between each resident.

Licensure Reference Number 175NAC 12-006.04 Based on record review and interview, the facility failed to ensure the Nurse Aide Registry verification was done for 1 staff member, CNA (Certified Nursing Assistant)-E . This affected one of 5 employee files sampled. A record review of CNA E's employee file revealed no documentation of licensure verification was completed prior to hiring. An interview with HR (Human Resources) staff- F confirmed no license verification for new hire CNA [NAME] was on file. An interview completed on 01/30/20 at 02:54 PM with DON (Director of Nursing) confirmed CNA E's Nurse Aide Registration verification was not completed prior to hire.

Based on record review and interview the facility failed to ensure facility assessment reflected specific staffing and training information. The facility census was 46. Findings are: Record review of facility assessment, not dated revealed the following information: Under staffing facility staffing needs are adjusted daily, no specifics outlined in facility assessment. Under training facility assessment reflects training will be provided for all staff. An interview on 01/30/20 at 03:50 PM with Administrator confirmed facility assessment specifics were not on facility assessment for staffing and training.